After Breast Cancer, Many Women Lack Options

Women diagnosed with an early stage of breast cancer face enough tough decisions, like choosing between prolonged therapies or major surgery. Yet, new research indicates doctors aren't even talking about every option available to women before a decision on how to proceed is made.

A new survey reports only one out of three breast cancer patients said they had talked with their doctors about plastic surgery options to reconstruct a lost breast.

The study, published in the Journal of the American Cancer Society, surveyed nearly 1,200 early stage breast cancer patients in Detroit and Los Angeles. The women who learned about breast reconstruction were four times more likely to choose mastectomy over lumpectomy.

Rebecca Larson, 31, was diagnosed with breast cancer in 2006. "I had no idea what my options for reconstruction were at diagnosis, or even before the first mastectomy," Larson said.

"No one talked to me, and my plastic surgeon was left out of the loop until well after the initial surgery," she added.

Cut out the tumor and get radiation, or get a mastectomy and remove the breast. Both treatments have high five-year survival rates. Both come with their own trade-offs of time, self-esteem and peace of mind, experts say.

Doctor's Discussion

The popularity of breast reconstruction surgery nationwide shows inconsistencies within geographic regions. In Hawaii, 8 percent of women who get a mastectomy have immediate reconstructive surgery. In Iowa, the figure is 11 percent; in New Mexico, it is 22 percent.

"If you think of it, women aren't that different," said Dr. Amy Alderman, lead author of the reconstruction study in cancer, and a plastic surgeon at the University of Michigan Medical Center.

Alderman's research tries to determine if surgeon preferences, rather than patient preferences, are driving reconstruction disparities. She thinks the wide variations in plastic surgery rates may come from regional medical communities' attitudes toward breast reconstruction.

The conversation between a surgeon and a breast cancer patient has been considered so crucial by public health advocates, that several states passed laws 20 years ago to standardize it.

In Pennsylvania, women must sign an informed consent waiver, stating they have discussed all treatment options before proceeding with their surgery. Previous laws tried to change the habit of performing mastectomies in favor of lumpectomies, which give some women a chance to keep more breast tissue.

Today, lumpectomies make up 65 percent of early stage breast cancer treatments, according to Dr. Freya Schnabel, director of breast surgery at New York University Medical Center.

Now, experts think the missing conversations might be about immediate breast reconstruction after a mastectomy, a procedure that combines a mastectomy and plastic surgery in one longer operation.

In 1998, Congress passed the Women's Health and Cancer Rights Act, which forced health insurance companies to cover reconstructive breast surgery for all mastectomy patients, for life.

Lillie Shockney, administrative director and assistant professor at the Johns Hopkins Breast Center, testified before Congress in support of the bill.

At the time, Shockney contacted 16 insurance companies to see if they covered testicular implants after testicular cancer, and they all did.

In her testimony, she recalls saying, "I said, 'gentlemen, it's our turn; I can't see what you've got down there, but you can see what I've got up here."

Importance of Choice

Provided a woman is a good candidate for the five-hour-long reconstructive surgery, immediate reconstruction can save a patient a second round of a four-week recovery after breast surgery.

Some women elect to have mastectomies, when a lumpectomy is an option, because they don't want to carry around the worry. Patients often say, "I'm not going to trust that, I want the breast off," said Anne Rosenberg, clinical professor of surgery at Thomas Jefferson University Hospital.

For women who choose mastectomy, or for women who had no choice, providing immediate breast reconstruction surgery for all eligible women might be a difficult challenge.

One factor might be the limited surgery resources of an area, says Rosenberg.

Reconstruction requires a general surgeon to find a consulting plastic surgeon and to coordinate operation time — a difficult task for a stand-alone general surgeon with a private practice.